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PLUMBI NG-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUTLDER DELCARATION <br />I hacty affm undq poalty of pojury thd I m qmpt Eom thc CortrsctoB' Licc l:w &r thc followilg ren (Sc.7031.5 <br />Bsins ed Prcfsion Codc): Any City or County which rcquiro a po'mit to @Elruct, alts, imprcvq danolbh or rtpair uy <br />stnrclw, prior to its isumcc, also rcquis thc applicet for such pqmit to filc a signcd statmt thst hc or stE k licascd pllMt <br />to thc Fovisioc of thc Cotrtretor's Licascd Lrw (Chapts 9. Commcing with Sction 7000 of Division I of thc BEiB ed <br />ProfcsiomCodc)orthalhcorshcisamptthscfromedthcbasisforthcallcgcdcrmFion. AnyviolntionofScrion?03l.5bymy <br />applicut for I psmit subj4ts the rpplicut to a civil pmlty of trot morc th8 nvc hundrcd dollrs ($500). <br />-1. <br />as owner of the property. or my employecs with wages as their sole compensation. will do thc work and the stnsure is not <br />intcnded or off€red for sale (Sec.70l4, Business and Professions Code: The Contraclor's License law does not apply to an owner of <br />thc p,roperty who builds or improves thcreon ard who docs such wort himself or hcrsclf or through his or her own cmployecs. <br />providcd that such impnovonents arc not intendcd or offtrod for sale. I[, howevcr, the hlilding or improvcmcnt is sold within onc ycar <br />of complaion. the Orvner Builder witl have the hrden of proving ttrrm he or she did not build or improve the propcty for the purposcof <br />sale). <br />-1, <br />as owner ofthe propcrty, am exclusively contracting with licenscd contractoni to construct ttrc project (Sec. 7044, Business <br />ad hoftssbn Code: The Contractor's License Law does not apply to an owner of property who builds or improves thcreon <br />and who contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's Licerue t aw). <br />-l <br />am exempt under Section-, B. & P.C. for this reason. <br />Ilolo. <br />WORKERS' COMPENSATION <br />DECLARATION <br />I hereby affrrm under penalty of perjury one of the following declarations: <br />-l <br />have and will maintain a Certificatc of Conscnt to Self-lnsure for workers' compersation, as provided for by Section 3700 of the <br />I-abor Code. for the pcrfonnance of the work for which the perrnit is issued. <br />-l <br />have and will rnaintain workers' compensation insurance, as required by Scction 3700 of the Labor Codc. for the performance of <br />the work for which this permit is issued. My workers' compensation insurance carier and policy number are: <br />that in the pcrformancc of the work for which this permit is issued. I shall not cmploy any person in any manner <br />if I should becomc subject to the <br />comply with thosc provisions.. <br />to the workcrs'compensation laws of California. and agrce that <br />provisions of Section 3700 of the [^abor Code. I shall. forthwith <br />I <br />WARNING: Failure to secure workers' compensation coveragc is unlawful. and shall subject an anployer to criminal penalties and <br />civil fines up to one hundred thousand dollars ($100,000). in addition to the cost of compcnsation, damages as provided for the <br />3076 of the Labor Codc interest and attorney's fees. <br />6 DECTI\RATION <br />I am licensod under provision of Chapto 9 (commancing with Sectbn 7000) of Division 3I hereby affrm under <br />of the Business and Professions Code, and my licensc is in full force and effect. <br />2/ <br />W <br />I hacbyslfrmundrr FultyofFjurythd ilreb8@GrnE{ioo Lnditrgr8my forthcpafomofthccrcd( bruticlrthbpmit i <br />isucd (Sc. 3097, Civ. C.). <br />Lender's Name: <br />Lender's Addr&s: <br />APPLICANT NECII\RATION <br />I hq'*y affirm undcr pcnalty of pcrjury onc of the following declarations: <br />Denrolition Permits-Asbestos Notifrcation Fcderal Regulations (Tille 40, Part6) <br />_Requirod [rtter o f Notification <br />-l <br />certi$ that the lederal regulations regarding asbcstos removal are not applicable to this projed. <br />'-1 >.r.cdifo that I have read this application and state that the above infonnation is correct. I agree to cornply with all City and County <br />ordinances and State I-aws relating to building consruction.represcntatives of this City and County to €ntcr upon thc <br />$ermitee <br />nrme <br />for q and hereby uurlrs4zcw/*"'5/#/ rod <br />UNDER GROUND t <br />Waste & Vent d19-u (bc 7 I <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />I nterceptor/ Clarifier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq A.l5 {.1 (/-v/ I <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />Main Drain/Pool Piping I <br />Fill Line/Back FIow <br />Pool Heater/Gas Line <br />\ <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler \ <br />Sanitary SewerlCao / <br />Back FIow Device I <br />Roush Plumbins <br />Final Gas Test <br />Meter Release <br />FINAL 7.2gel L (},r )rt€Jb5'41 <br />Notes, Remarks, Etc. <br />x <br />) <br />,/ <br />Owner: <br />Carrier:- <br />.Expires: <br />\9pq7,[/F <br />5 c' <br />D JicenseNumbcr: /'k1 <br />[X^""",,, llQw B&YV <br />{ <br />Date:_5 /J 4 /24L d